Examination Engagement for Review of Medicare Advantage Organizations and Prescription Drug Plans Financial Information

Examination Engagement for Review of Medicare Advantage Organizations and Prescription Drug Plans Financial Information THIS IS NOT A FORMAL REQUEST FOR PROPOSAL (RFP) AND DOES NOT COMMIT THE CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS) TO AWARD A CONTRACT NOW OR IN THE FUTURE. This is a SOURCES SOUGHT NOTICE to determine the availability of companies (small, large, disadvantaged, other) that are qualified to support CMS in the examination engagements for the review of the Medicare Advantage Organizations (MAOs) and Prescription Drug Plans (PDPs). Background: From the beginning of the Medicare program in 1965, Medicare has recognized the unique nature of Health Maintenance Organizations (HMOs) and HMO-like entities and has provided for alternative payment methodologies appropriate for such organizations. The original Medicare amendments to the Social Security Act included the authority for prepaid plans to receive payments for physician services on a basis other than individual charges. Even before the enactment of the federal HMO Act in 1973, the 1972 amendments to the Social Security Act provided authority to contract with HMOs on a risk-sharing basis and on a cost basis. The Tax Equity and Fiscal Responsibility Act (TEFRA) was passed in September 1982 in which Congress mandated the provision of managed care plan options to Medicare beneficiaries. The statute allowed Medicare beneficiaries to enroll in HMOs reimbursed on a cost basis (also known as MCOs) or - risk-contracting HMOs. HMOs reimbursed on a cost basis are reimbursed for - reasonable cost incurred for Medicare covered services rendered, related administration on those medical services, plan administration, and a defined special administration. The special administration is reimbursed 100%. In 1996, Section 202 of the Health Insurance Portability and Accountability Act (HIPAA) added section 1893, to the Social Security Act. Section 1893 established the Medicare Integrity Program (MIP). MIP was established to strengthen CMS's ability to deter waste, fraud and abuse in the Medicare program. It provides for separate and stable long term funding for MIP activities. MIP expands CMS's contracting authority so the agency can more aggressively carry out program safeguard functions. The Balanced Budget Act of 1997 (BBA) established the Medicare+Choice (M+C) program, allowing additional types of managed care organizations to secure Medicare contracts. A major intent of the BBA was to replace TEFRA with a new managed care options (i.e. M+C plans, etc.) for beneficiaries. It allowed for new beneficiary options in addition to the well established types of HMO options operating under TEFRA contracts. The recently-enacted Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) has expanded the role of private entities in providing benefits to Medicare beneficiaries. First, the law adds a new section to the Social Security Act, 1860D (Part D) that offers prescription benefits beginning in 2006 through Prescription Drug Plans (PDPs). Secondly, the statute allows for payments to Medicare Advantage Organizations (MAOs) - local plans formerly M+C plans, and creates a new type of private plan, - Regional MA plans or Regional Preferred Provider Organizations (RPPOs). CMS's Office of Financial Management (OFM) has overall responsibility for the fiscal integrity of all Agency programs which includes the mandated one-third financial audit requirement. OFM will conduct annual audits of the financial records of at least one third of the MAOs and PDPs as required by Sections 1857(d)(1) and 1860D-12 of the Social Security Act. Description of work: The main objectives of the examinations are to provide assurance that Medicare Advantage and Prescription Drug payments were proper and organizations self reported information used to determine payment amounts were valid and correct. The audit contractor shall document the results of the examination, extrapolate the value of appropriate exceptions to the entire population and propose payment adjustments. The examination engagements shall be made in accordance with the Uniform Examination Program (UEP) for Review of the Medicare Advantage Organizations (MAO) and Prescription Drug Plans (PDP) which, includes: - Governmental Accounting Standards Board (GASB) - Generally Accepted Accounting Procedures (GAAP) - Generally Accepted Auditing Standards (GAAS) - Generally Accepted Government Auditing Standards (GAGAS). - American Institute of Certified Public Accountants (AICPA) - General Accounting Office Government Auditing Standards (2007 revision, Yellow Book) - Social Security Act (the Act) Titles XVIII and XIX and; the Code of Federal Regulation (CFR) governing the MAO program including, standards and processes for imposing the enforcement provisions. - Medicare Advantage (MA) contractor Performance Monitoring System, November 30, 1999, Final and Publication 75. Contractor Performance Monitoring System-Pub. 75 - Budget and Accounting Procedures Act of 1950 - Federal Manager's Financial Integrity Act of 1982 (FMFIA), GAO Title II - Chief Financial Officer Act of 1990 - Committee of Sponsoring Organizations of the Treadway Commission (COSO) Report PLEASE NOTE: Any potential offeror must demonstrate the following: - Thorough understanding of the operations, policies, regulatory requirements, and payment methodologies for the Medicare Advantage program. - Thorough understanding of the operations, policies, regulatory requirements, and payment methodologies of the Medicare Prescription Drug Program (including prescription drug events, true out of pocket costs, direct and indirect remuneration). - A complete understanding of the Medicare Prescription Drug payment reconciliation process. - Ability to work with the Health Plan Management System (HPMS). - Ability to maintain and manage large size data files while ensuring security of confidential information. - Effective communication with all parties involved. - Proficient use of Access database. Business Information: Please include the following in your response. a. DUNS b. Company Name c. Company Address d. Current GSA Schedules appropriate to this Sources Sought Note: CMS intends to award the following contract under GSA Schedule 520 entitled, - Financial Accounting Business Solutions (FABS). e. Do you have a Government approved accounting system? If so, please identify the agency that approved the system. f. Type of Company (i.e., small business, 8(a), woman owned, veteran owned, etc.) as validated via the Central Contractor Registration (CCR). All contractors must register on the CCR located at http://www.ccr.gov/index.asp. g. Company Point of Contact, Phone and Email address h. Point of Contact, Phone and Email address of individuals who can verify the demonstrated capabilities identified in the responses. i. Provide the NAICS code in which you would operate under for this service Responses (capability statements) must be submitted and/or postmarked no later than Wednesday, January 14, 2009 COB. All capability statements can be submitted via e-mail (preferred) or regular mail to the point of contact listed below. Responses shall be limited to 10 pages. Capability statements will not be returned. CMS shall not be responsible to answer questions about this notice. This is not an invitation for bid, request for proposal or other solicitation and in no way obligates CMS to award a contract. The sole intent is to obtain capabilities for contractors and procurement planning purposes. Documentation should be sent to: Centers for Medicare & Medicaid Services Attn: Liz Hammond, Contract Specialist Office of Acquisitions and Grants Management Acquisitions and Grants Group Division of Medicare Support Contracts Mailstop: C2-21-15 7500 Security Boulevard Baltimore, MD 21244 Point of Contact Name: Liz Hammond, Contract Specialist Phone: 410-786-7440 Email: elizabeth.hammond@cms.hhs.gov (End of text)